UMass Memorial Medical Center

Introduction: Pediatric extra-corporeal membrane oxygenation (ECMO) is an advanced therapy offered by few centers. Often, patients with severe cardiopulmonary failure undergo urgent transfer from pediatric intensive care units (PICUs) to an ECMO center for potential cannulation. Given the risks associated with ECMO and transport, it is crucial to identify patients most likely to benefit from transfer and ECMO support. Our objective was to determine the rates of and factors contributing to receipt of ECMO and survival of children urgently transferred to an ECMO center. Methods: We performed a multicenter retrospective cohort study of patients 0-18 years referred by 5 PICUs to a pediatric ECMO center in the U.S. Northeast from 2013-2022. We excluded patients already on ECMO at referral and those referred for procedures needing ECMO back-up (not imminently requiring support). Patients’ records were linked across referring PICUs and the ECMO center. We collected demographic data, referral/transfer characteristics, clinical data at various timepoints, and patient outcomes. Results: Preliminary results from completed reviews of 37 records showed that 36 (97%) referred patients were transferred to the ECMO center. One patient did not transfer due to clinical improvement. Mean referral time from PICU admission was 2.3 (SD 3.2) days and transfer occurred at a median of 6.5 (IQR 4.9, 8.6) hours from initial referral. Eight (22%) patients were cannulated onto ECMO at a median of 8.4 (IQR 4.4, 13.9) hours from ECMO center admission. Six (17%) patients died, all after transfer to the ECMO center, including 4 (50%) patients placed on ECMO. Unadjusted analysis showed that patients who received ECMO support were older (median 1.5 vs. 0.5 years), and at transfer, were more severely ill (median PRISM-III score 19.5 vs. 9) with greater life support needs (median OI 12.1 vs. 8.9 and median VIS 10 vs. 7.5). Conclusions: In a regional pediatric ECMO referral network, 22% of referred patients subsequently received ECMO support, with a 17% mortality rate among all referred patients. Factors associated with ECMO cannulation will be determined using cluster analysis once data for the entire cohort is complete. Findings can potentially inform ECMO referral and transfer practices across a referral network.

Lung biopsy has traditionally played a fundamental role in addressing diagnostic uncertainty and guiding management of fibrotic interstitial lung disease (fILD). Multiple lung biopsy procedures are available for evaluating fILD, including bronchoscopic techniques such as transbronchial biopsy and transbronchial lung cryobiopsy, as well as surgical lung biopsy, which is now almost exclusively conducted using minimally invasive video-assisted thoracoscopic surgery. The various evolving -considerations for and against lung biopsy have led to substantial ambiguity regarding the optimal timing and choice of biopsy method. The rationale for performing a lung biopsy in fILD is multifaceted, shaped by its potential to enhance diagnostic confidence and inform therapeutic decisions, weighed against procedural risks, and further nuanced by patient values and preferences. The objective of this state-of-the-art document from a multidisciplinary group of experts and patient representatives is to summarize the rationale for and against lung biopsy in the evaluation and management of fILD. Amid ongoing technological innovations, we further emphasize that future research should prioritize the development and validation of minimally invasive and noninvasive modalities that may serve as either alternatives or adjuncts to biopsy in the diagnostic evaluation of fILD.

Previous single-center studies conducted in the United States in women with suspected preeclampsia indicated that serum soluble fms-like tyrosine kinase 1-to-placental growth factor ratio values of >38 measured on a widely available Elecsys immunoassay platform during the third trimester of pregnancy predicted the development of preeclampsia with severe features and adverse outcomes within 2 weeks of testing. This study aimed to validate the Elecsys soluble fms-like tyrosine kinase 1-to-placental growth factor ratio test for the prediction of preeclampsia with severe features in a United States population using the prospective Preeclampsia Risk Assessment: Evaluation of Cut-offs to Improve Stratification cohort that recruited women with a hypertensive disorder of pregnancy (gestational hypertension, chronic hypertension, de novo and superimposed preeclampsia) across 18 tertiary and community hospitals throughout the United States. We measured soluble fms-like tyrosine kinase 1-to-placental growth factor ratios using the Elecsys platform in archived serum samples from the Preeclampsia Risk Assessment: Evaluation of Cut-offs to Improve Stratification study that recruited hospitalized women with a hypertensive disorder of pregnancy between 23 0/7 and 34 6/7 weeks of gestation. The primary study outcome was prediction of preeclampsia with severe features within 2 weeks after testing. The secondary outcomes included a composite of adverse maternal and fetal/neonatal outcomes and prediction of delivery within 2 weeks. In the validation cohort of the Preeclampsia Risk Assessment: Evaluation of Cut-offs to Improve Stratification study (556 enrollments), the serum soluble fms-like tyrosine kinase 1-to-placental growth factor ratio at a cutoff value of >38 demonstrated a 67% positive predictive value (95% confidence interval, 61-73) and a 95% negative predictive value (95% confidence interval, 92-97) for the progression to preeclampsia with severe features within 2 weeks. Among women at <30 weeks of gestation (n=188), serum soluble fms-like tyrosine kinase 1-to-placental growth factor ratio at a cutoff value of >38 demonstrated a 78% positive predictive value (95% confidence interval, 68-86) and a 100% negative predictive value (95% confidence interval, 96-100) for the progression to preeclampsia with severe features within 2 weeks. The Elecsys soluble fms-like tyrosine kinase 1-to-placental growth factor ratio test performed better than standard-of-care clinical measures, with an area under the receiver operating characteristic curve of 0.92 (95% confidence interval, 0.89-0.90) for soluble fms-like tyrosine kinase 1-to-placental growth factor ratio vs <0.70 for standard-of-care tests, such as liver enzymes, platelet count, and serum creatinine (P<.001). Compared with women with a ratio of ≤38, those with a ratio of >38 had a higher risk of developing adverse maternal (relative risk, 4.9 [95% confidence interval, 2.6-9.9]; P<.001) and fetal/neonatal (relative risk, 3.2 [95% confidence interval, 2.6-4.0]; P<.001) outcomes and were more likely to deliver within 2 weeks (adjusted hazard ratio, 3.3 [95% confidence interval, 2.7-4.0]; P<.001). The soluble fms-like tyrosine kinase 1-to-placental growth factor ratio of >38 measured on the Elecsys platform predicted the development of preeclampsia with severe features, delivery, and adverse maternal and fetal/neonatal outcomes within 2 weeks of testing among preterm pregnant women hospitalized with a hypertensive disorder of pregnancy.

Abstract Background Acute respiratory tract infections (ARTIs) account for a large share of inappropriate prescribing in the outpatient setting. Telemedicine may offer one strategy to improve prescribing. We aimed to develop a risk prediction model to identify patients at low-risk for complications who can be safely seen via a telehealth visit for an ARTI. Methods We performed a retrospective analysis of adult primary care visits for patients with an ARTI seen in the outpatient setting at three Boston area hospitals from 2017-2021. We used aLasso regression for the final model to predict admission to an observation or inpatient unit within 14 days post ARTI visit in the derivation cohort and validated the model in two external cohorts. We evaluated prediction performance using the area under the curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) along with their 95% confidence intervals. Results Approximately 1% of patients across all three cohorts had either an admission to an observation unit or an inpatient admission. The final prediction model included heart disease, diabetes, cancer, chronic obstructive pulmonary disease, insulin use, prior antibiotic prescription use, prior visit in the past 30 days and age. The AUC across the three cohorts ranged 0.72-0.81. The PPV ranged 0.02-0.04. The majority of patients were classified as low risk 74%-80% and only a small percentage (1%-3%) across all sites were classified as high risk for hospitalization. Conclusions Serious outcomes in patients with ARTIs are rare and most patient with an ARTI can be safely seen via telehealth.

Introduction:The COVID-19 pandemic and subsequent influenza outbreaks highlighted disparities in timely access to tests and treatments. To address this gap, a nationwide Home Test to Treat (HTTT) program was launched to provide home test kits, telehealth consultations, and medication delivery for COVID-19 and influenza. This study explored participant experiences, factors influencing satisfaction levels, and recommendations for future programs.Methods:In-depth interviews were conducted with 48 participants enrolled in the HTTT program. Purposive sampling was used to obtain experiences from diverse backgrounds. Content analysis was used to extract the final coding scheme.Results:Interviewees reported a range of experiences, from positive to negative. Many of them were satisfied with efficient communication with telehealth providers, timely and convenient access to resources, and a seamless transition from enrollment to prescription. However, some interviewees noted limited interactions with telehealth providers, delayed access to treatment and cost challenges, and navigation and coordination challenges. For a future home-based Teat to Treat program, interviewees recommended improving inclusivity, offering more comprehensive consultation, enhancing user-friendliness, and increasing awareness through diverse platformsDiscussion:This study highlights a home-based Test to Treat program as a feasible way to improve access to COVID-19 and influenza care. Enhancing interactions with providers, comprehensive care, and support for marginalized populations may further expand the program and reduce disparities in access to tests and treatments.